Prof. dr. Nova Kapantow, DAN., MSc., SpGK

TUNJANGAN NUTRISITERHADAP

BENCANA PERUT

MODUL BENCANA PERUT

TUNJANGAN NUTRISI

BENCANA PERUT

GI TIDAK BERFUNGSI

NUTRISI PARENTERAL

GI BERFUNGSI

NUTRISI ENTERAL

metode pemberian mkn melalui jalur IV.=intravenous feeding ok lgs dimasukkan ke

sirkulasi sistemik tanpa melalui sirkulasi portal dan sistim limfatik.

Zat gizi yg diberikan: btk terdigesti dan steril

Parenteral Nutrition

Parenteral Nutrition

1. Indications, Contraindications and Routes of Administration

2. Macronutrient and Micronutrient Use in TPN

Common Indications for PN

Inability to absorb adequate nutrients via the GI tract : Massive small-bowel resection / short

bowel syndrome Severe, untreatable steatorrhea /

diarrhoea / malabsorption Complete bowel obstruction, or intestinal

pseudo-obstruction Prolonged acute abdomen or ileus

Common Indications for PN

Severe catabolism & GI tract unusable within 5–7 days

Enteral access not feasible, not adequate or not tolerated

Pancreatitis with intolerance (eg pain) of jejunal nutrition

High output EC fistula (>500 mL) & no distal enteral access

Potential Indications for PN

Enterocutaneous fistula IBD unresponsive to medical therapyPartial small bowel obstruction Intensive chemotherapy / severe

mucositis Intractable vomiting if jejunal feeding

not possible

Contra-indications to PN Functioning gastrointestinal tract

Treatment anticipated for < 5 days in patients without severe malnutrition

Inability to obtain venous access

Poor prognosis that does not warrant aggressive nutrition support

When the risks of PN are judged to exceed the potential benefits

How Do We Give PN?

Administration of PN

PN solutions are hypertonicInfusion, therefore, via:

Central venous catheter, or Peripheral venous catheter with

*reduced* osmolarity

Rute pembuluh darah sentral

Central sites: Internal jugular vein

Subclavian veinFemoral vein

Percutaneous CentralVenous Access

Peripherally inserted central catheters: PICC Placed at bedside or radiologically

Subclavian vein – used to be most common Can be placed & removed at bedside, but Generally, placed radiologically Confirm placement with chest x-ray Can change over a wire to replace

Peripherally Inserted Central Catheter (P.I.C.C.) Line

Tip in SVC

O

• More expensive than peripheral lines

• More difficult to place• Last up to 6 - 12 months• Restrict arm movement• Allow higher osmolarity

“Central” TPN solutions

Implanted Central Venous Catheters (e.g. Hickman, Groshong, Port-A-Cath)

For prolonged TPN: Also for fluids, chemotherapy, blood draws

Catheter inserted ‘operatively’Placed with fluoroscopic guidance Implanted into a subcutaneous tunnel

Tunnelled (“Hickman”) Line

Implanted Venous Access Device

Central IV: PICCPROS Can infuse solutions

> 900 mOsmol/l May be placed by RN Decreased CRI vs

other central lines: HPN Can be multi-lumen Usable for CT contrast

CONS Shorter life than other

central lines (< 12 m) More difficult self care Blood sampling not

always possible More frequent flushing

and maintenance More painful

Central IV: Hickman / BrovacPROS Can infuse solutions

> 900 mOsmol/l Allow full IV nutritional

support Can be multi-lumen Longevity: 1 -3 years Easier self-care (than

PICC &, possibly, port)

CONS Surgical / Radiological

procedure More complex More difficult to remove

Tube protruding from chest may affect body image

More restrictive than a port

Central IV: Implantable PortPROS Can infuse solutions

> 900 mOsmol/l Allow full IV nutritional

support Greatest longevity Easier self-care (only

needed if accessed) Improved body image &

activity

CONS Surgical / Radiological

procedure More complex More difficult to remove

Access requires placement of a Huber needle

Infection risk during access

Rute pembuluh darah perifer

Peripheral IV: short-linePROS Least expensive Easily placed and

removed Lowest risk for CRI Beneficial for short-

term support (< 1 week)

CONS Need to change often

Every 48-72h

Phlebitis and vein injury Only one lumen Limits energy delivery

Volume Osmolality (600-900

mOsm/l) pH restriction (pH 5-9)

Peripheral IV: mid-linePROS May be used for a

longer duration than peripheral

Ease of placement compared to central lines

Allows access to larger vessel

CONS Not a central line Must follow guidelines

for peripheral lines for concentration, pH and infusion rates

Metabolik Komplikasi dini:

Vol. berlebihan, hiperglikemia, refeeding syndrome, dll

Komplikasi lanjut: Def. A. lemak esensial, def. trace mineral, def. vit,

penyakit tulang metabolik, steatosis hepatik, dan kolestasis hepatik.

Ketidakseimbangan cairan dan elektrolit

Complications of PN

Complications of PN Catheters

Catheter infectionsCatheter occlusionCatheter injury/leakageCatheter migrationVenous thrombosis

Risk Factors for Infection

Site - Subclavian < Int. jugular < Femoral Material - Silastic / Polyurethane < PVC Type - Subclavian (0.9) < PICC (1.4 / 1000d)

- Single lumen < Multi-lumen Care - 2% chlorhexidine (5.9 % catheter colonisation)

70% isopropyl alcohol (15.6%) 10% povidone iodine (19.5%)

Patient - young, poor technique, smoking, Crohn’s, jejunostomy, thrombosis, narcotics

Macronutrient and Micronutrient Use in TPN

Formula

Larutan utk NP sentral diformulasi bdsrkn perhitungan kebutuhan protein dan energi

Pada beb. keadaan (mis. ketidak-seimbangan elektrolit atau tdpt disfungsi organ, maka komposisi disesuaikan dg kondisi p/.

Designing Parenteral Regimens Assess nutritional status and set goals. Evaluate constraints on nutrient delivery. Assess fluid, electrolyte, vitamin, trace element

requirements Order nutrients (protein, CHO, fat), fluids/

electrolytes/ trace elements Determine administration (rate and duration). Avoid metabolic complications.

Parenteral NutritionCarbohydrate (10 - 25% Dextrose)Amino Acids (0.8 to 1.2 g /kg)Lipid Emulsion, incl E.F.A. (10 - 30%)Vitamins / Minerals / Trace ElementsElectrolytesFluid (2 - 3 litres /day)

How Much Should We Give?

Estimate of Requirements

Most hospitalized patients will require 30 kcals/kg/dCHO – can utilise dextrose up to 5

mg/kg/min

Protein – The average patient requires 0.8 – 2.0 g protein/kg usual body weight

Constraints on Nutrient Delivery

Do not overload body’s disposal systems

renal, hepatic, respiratory

Nutritional regimen should make sense clinically

Composition of Standard Parenteral Dextrose Solutions

5% - 70% solution dextrose in water

3.4 kcal/gm

500 ml of a 50% solution contains

50 gm/100 ml x 500 ml = 250 gm dextrose

250 gm x 3.4 kcal/gm = 850 kcal

Composition of Standard Parenteral Amino Acid Solutions

Synthetic crystalline amino acidsContain essential and non-essential AAVariable amounts of electrolytesConcentrations depend on final volumeHypertonic solutions

Characteristics ofIntravenous Lipid Emulsions

Concentrations 10% and 20%

Parent oil Soybean or Safflower

Osmolarity 280 - 340 mOsm/l

Caloric content 10% = 1.1 kcal/ml20% = 2.0 kcal/ml

Electrolytes in Parenteral Nutrition Solutions

Appropriate prescription requires regular monitoring

For maintenance provision Add directly to the PN solution

Tailor to individual patient needs Additional replacement for abnormal losses Deletions for patients with certain diseases

Vitamins/Trace Elements in Parenteral Nutrition Solutions

Meet established guidelines for PN Water and fat-soluble vitamins provided Required for zinc, copper, manganese,

chromium & selenium Added daily to the solution Requirements may be increased for patients

with abnormal losses

Prosedur Standar Pemberian

Hari 1 : mulai dg 50 ml/jam Hari 2 : 75 ml/jam Hari 3 dst : 125 ml/jam

Pemberhentian: bertahap (dari 50% kmd 70% dlm 30-60 menit sebelum berhenti).

Ok dekstrosa menstimulasi sekresi insulin, dan level insulin akan tetap ↑ saat infus dextrosa dihentikan hipoglikemia.

Oki ↓ dosis bertahap cegah hipoglikemia.

15- 30

Monitoring Patients on Parenteral Nutrition

Clinical status

Metabolic and biochemical aspects

Delivery

Catheter care, pump, % volume infused

Nutritional status/reassessment

Thank You!

PN – Summary Guidelines1. Determine if PN is truly indicated2. Assess the patient (medical history, medication profile,

anthropometric data & lab values)3. Determine need for long-term vs. short term

<7–10 days

4. Confirm or establish adequate IV access Peripheral or central?

5. Determine estimated kcal, protein and lipid needs 20–30 kcal/kg Protein 0.8–1.5 gm/kg

Higher levels may be needed in severe catabolic states Lipid to provide ≤30% of kcals

PN – Summary Guidelines6. Determine initial electrolyte, vitamin and trace element

requirements; consider ongoing losses7. Consider any additional additives to PN formulation

including insulin and H2-receptor antagonists

8. Monitor for: Risk of refeeding syndrome Glucose intolerance

Start low & advance slowly if labs stable over 24-48 hours Fluid, electrolyte, metabolic, macro- and micro-nutrient changes Complications – sepsis, thrombosis, abuse

9. Initiate trophic feedings or convert patient to PO or enteral feeding when feasible